WASHINGTON — As Republicans in Congress work to repeal and replace the Affordable Care Act, many say they want to keep guaranteed insurance for people with pre-existing medical problems.

However, fissures are emerging among Republicans trying to decide what that means.

Two proposals — one backed by Republican Sens. Johnny Isakson, of Georgia, and Shelley Moore Capito, of West Virginia, and another by Kentucky Sen. Rand Paul — illustrate their differences.

Both plans remove an Obamacare mandate for all adults to get insurance. But Republicans appear divided over the extent to which government should force insurers to cover people with persistent medical conditions.

The proposals underscore the difficulty in finding agreement on a replacement to the Affordable Care Act. They could also signal that Congress is moving toward a plan that does not provide the same assurances as the current law.

Among those pushing for no requirement is Sen. Patrick Toomey, R-Pa.

“We agree we have to make sure those people get the health care they need,” Toomey said at a Tuesday confirmation hearing for Rep. Tom Price, who is President Donald Trump’s nominee to head the Department of Health and Human Services.

Toomey said requiring insurers to cover people with pre-existing conditions is “like asking the property-casualty company to rebuild the house after it has burned down.”

He asked Price, a Georgia Republican who is expected to take a leading role in creating Trump’s health care proposal, if he agrees there are better approaches.

“I think there are other options,” Price said.

On Monday, Isakson and Capito backed a bill by Sens. Bill Cassidy, R-La., and Susan Collins, R-Maine, to allow some government mandate on insurers to cover pre-existing conditions. But it gives the states wide latitude in implementing it.

The Cassidy and Collins plan gives states the option of maintaining Obamacare mandates. Under that arrangement, states could get 95 percent of what the federal government now gives them in Obamacare funding, including money to enroll millions of people who wouldn’t otherwise qualify for Medicaid.

They also could choose to put the money into health care savings accounts for recipients. They also would have to require insurers cover people with existing medical conditions.

However, Karen Pollitz, senior fellow for insurance and health care reform at the Kaiser Family Foundation, said there would be conditions.

For example, people with pre-existing conditions would be required to have 63 continuous days of coverage to still have a right to coverage.

Many people lose insurance at some point, she noted, particularly if they lose their jobs.

Those with lapsed insurance could find coverage in new state programs at rates that do not take their conditions into account, or through more expensive policies, said a Capito spokeswoman who called the plan a “first step” toward consensus.

The Cassidy and Collins proposal also lets states turn down federal funding and not be subject to federal regulations – including the rule on pre-existing conditions.

Neither Isakson nor Capito were available to comment about the plan on Wednesday, as Congressional Republicans began a two-day retreat in Philadelphia, partly to discuss how to move forward with a replacement for Obamacare.

In a press release, Isakson and Capito said the plan dumps costly government mandates and empowers state officials who know best what their communities need.

Both said the plan protects people with pre-existing conditions.

In a report Wednesday, the Center on Insurance Reforms at Georgetown University said leaving decisions over pre-existing conditions to states has pitfalls.

Prior to the Affordable Care Act, states allowed insurers to make those with existing conditions wait months before their coverage kicked in.

Nine states, including Oklahoma, had no limit on how long insurers could make people wait. In Massachusetts, insurers could hold back coverage for up to six months. The allowed delay was 12 months in Kentucky, Pennsylvania and Texas, and in Georgia and West Virginia it was two years.

The issue is important, particularly in states such as Georgia, Kentucky and West Virginia where a higher number of people suffer chronic illness, according to the Kaiser Foundation.

Kaiser’s associate director for women’s health policy, Usha Ranji, told reporters Wednesday the issue is especially important for women, as well.

Paul, in a call with reporters, doubted that Republicans will unite behind the Cassidy and Collins’ plan because it keeps in place Obamacare’s tax system. He also doubted Republicans will support an approach of allowing states to keep the Affordable Care Act’s requirements.

“‘If you really love Obamacare, you can keep it,’ is not a rallying cry many Republicans are going to want to rally around,” he said.

Paul said he’s proposing a “free market” approach that dumps “regulations that have prevented inexpensive insurance from being sold,” including a requirement on insurers to provide coverage to the sick.

His plan gives everyone $5,000 for a health care savings account. Consumers will also be allowed to group together to buy coverage, using their numbers of negotiate better prices as well as coverage for people with pre-existing conditions.

But Pollitz said the idea has been tried, and insurance companies insisted on charging those in associations with persistent medical conditions high rates.

Toomey spokeswoman E.R. Anderson said in an email that even without a government mandate, people with chronic conditions can buy insurance in state-subsidized pools, along with others who’ve been denied insurance because of their health.

Health care experts have said that idea also has its problems, however. The insurance pools have been underfunded, leading those involved to pay large premiums and deductibles.

Kery Murakami is the Washington, D.C. reporter for CNHI’s newspapers and websites. Contact him at kmurakami@cnhi.com.